Soft tissue repair device and associated methods

ABSTRACT

A soft tissue repair device. The device includes an inserter having a distal portion, a first anchor carried externally onto the distal portion, a second anchor carried externally onto the distal portion, and a flexible strand coupling the first and second anchors and forming an adjustable knotless loop.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.14/876,167 filed on Oct. 6, 2015, now issued as U.S. Pat. No.10,251,637, which is a continuation of U.S. patent application Ser. No.13/656,821 filed on Oct. 22, 2012, now issued as U.S. Pat. No.9,173,651, which is a divisional of U.S. patent application Ser. No.13/045,691 filed on Mar. 11, 2011, now issued as U.S. Pat. No.8,292,921, which is a divisional of U.S. patent application Ser. No.12/014,399 filed on Jan. 15, 2008, now issued as U.S. Pat. No.7,909,851, which is a continuation-in-part of U.S. patent applicationSer. No. 11/347,661 filed on Feb. 3, 2006, now issued as U.S. Pat. No.7,749,250, which is a continuation-in-part of U.S. patent applicationSer. No. 11/935,681 filed on Nov. 6, 2007, now issued as U.S. Pat. No.7,905,903, and is a continuation-in-part of U.S. patent application Ser.No. 11/869,440 filed on Oct. 9, 2007, now issued as U.S. Pat. No.7,857,830, which is a continuation-in-part of U.S. patent applicationSer. No. 11/408,282, filed on Apr. 20, 2006. U.S. patent applicationSer. No. 11/347,661, now issued as U.S. Pat. No. 7,749,250, is also acontinuation-in-part of U.S. patent application Ser. No. 11/541,506,filed on Sep. 29, 2006, now issued as U.S. Pat. No. 7,601,165. U.S.patent application Ser. No. 11/347,661, now issued as U.S. Pat. No.7,749,250, also claims the benefit of U.S. Provisional Application No.60/885,062, filed on Jan. 16, 2007, and of U.S. Provisional ApplicationNo. 60/885,057, filed on Jan. 16, 2007. The disclosures of the aboveapplications are incorporated herein by reference.

INTRODUCTION

Tears caused by trauma or disease in soft tissue, such as cartilage,ligament, or muscle, can be repaired by suturing. Various repair deviceshave been developed for facilitating suturing and are effective fortheir intended purposes. Nevertheless, tissue repair devices forfacilitating suturing are still desirable.

SUMMARY

The present teachings provide a soft tissue repair device. The devicecan include an inserter having a distal portion, first and secondanchors carried externally onto the distal portion, and a flexiblestrand coupling the first and second anchors and forming an adjustableknotless loop.

In one aspect, each of the first and second anchors is a flexible sleevehaving first and second ends and an internal passage between the firstand second ends. In another aspect, each of the first and second anchorsis substantially rigid having first and second ends and an internalpassage between the first and second ends.

The present teachings also provide a method for repairing a tear in ameniscus during arthroscopic knee procedure. The method includescoupling first and second anchors with a flexible strand, forming anadjustable knotless loop with the flexible strand, and loading the firstand second anchors coupled with the adjustable knotless loop on anexternal surface of an inserter. The method further includes insertingthe inserter through the tear to an outer surface of the meniscus,sequentially deploying the first and second anchors from the inserter onan outer surface of the meniscus, self-locking the adjustable loop, andreducing the tear.

Further areas of applicability of the present invention will becomeapparent from the description provided hereinafter. It should beunderstood that the description and specific examples are intended forpurposes of illustration only and are not intended to limit the scope ofthe invention.

BRIEF DESCRIPTION OF THE DRAWINGS

The present invention will become more fully understood from thedetailed description and the accompanying drawings, wherein:

FIG. 1 is a perspective view of a tissue repair device according to thepresent teachings shown in a first configuration;

FIG. 1A is a perspective view of a flexible anchor according to thepresent teachings;

FIG. 2 is a perspective view of the device of FIG. 1, shown in a secondconfiguration;

FIG. 3 is a perspective view of the device of FIG. 1, shown in a thirdconfiguration;

FIG. 4 is a perspective view of the device of FIG. 1, shown in a fourthconfiguration;

FIG. 5 is a perspective view of the device of FIG. 1, shown in a fifthconfiguration;

FIG. 6 is a perspective view of a tissue repair device according to thepresent teachings;

FIG. 7 is an enlarged side view of the device of FIG. 6, shown with adepth limiting device in a first position;

FIG. 8 is an enlarged side view of the device of FIG. 6, shown with adepth limiting device in a second position;

FIG. 9 is an environmental view showing one anchor deployed outside softtissue according to the present teachings; and

FIGS. 10 and 10A are environmental view showing two anchors deployedoutside soft tissue according to the present teachings;

FIG. 11 is a perspective view of a tissue repair device according to thepresent teachings shown in a first configuration;

FIG. 12 is a perspective view of the device of FIG. 11, shown in asecond configuration;

FIG. 13 is a perspective view of the device of FIG. 11, shown in a thirdconfiguration;

FIG. 13A is a perspective view of the device of FIG. 11 shown in afourth configuration;

FIG. 14 is a perspective view of a tissue repair device, according tothe present teachings, shown in a first configuration;

FIG. 14A is a perspective view of the device of FIG. 14, shown in asecond configuration;

FIG. 15 is a perspective view of the device of FIG. 14, shown in a thirdconfiguration;

FIG. 16 is a perspective view of a tissue repair device according to thepresent teachings;

FIG. 16A is an enlarged side view of the device of FIG. 16;

FIG. 17 is a perspective view of a tissue repair device according to thepresent teachings;

FIG. 17A is an enlarged side view of the device of FIG. 17;

FIG. 18 is an environmental view showing one anchor deployed outsidesoft tissue according to the present teachings;

FIGS. 19 and 19A are environmental views showing two anchors deployedoutside soft tissue according to the present teachings;

FIGS. 20, 21, 22, and 23 are sequential views illustrating an exemplarymethod of coupling first and second flexible anchors with a flexiblestrand, and FIG. 22A shows a detail of FIG. 22;

FIG. 24 is a perspective view of a flexible anchor coupled with aflexible strand;

FIG. 25A is a bottom view of an anchor according to the presentteachings;

FIG. 25B is a top view of the anchor of FIG. 25A;

FIG. 26 is a view illustrating coupling first and second anchors with aflexible strand according to the present teachings; and

FIG. 27 is a perspective view showing first and second anchors loadedonto an inserter according to the present teachings.

DESCRIPTION OF VARIOUS ASPECTS

The following description is merely exemplary in nature and is in no wayintended to limit the invention, its application, or uses. For example,although the present teachings are illustrated in an application formeniscus repair in knee surgery, the present teachings can also be usedfor repairing any fibrous tissue, such as muscle, ligament or tendon inan arthroscopic or other open procedure, including rotator cuffreconstruction, acromioclavicular (AC) reconstruction, anterior cruciateligament reconstruction (ACL) and generally for fastening tendons,grafts, or strands to fibrous tissue and bone.

An exemplary tissue repair device 100 according to the present teachingsis illustrated in FIG. 1. The device 100 can include an inserter 102, astop member or shaft 106 and a depth limiting device 250, such as aplastic tube that can be cut to desired length. The inserter 102 can beexternally pre-loaded on its outer surface with one or more flexibleanchors 150. Two anchors 150 are illustrated in FIG. 1 and arereferenced hereinafter as first and second anchors 150 a, 150 b, ifdesirable for further clarity. The letters “a” and “b” will also beappended to distinguish corresponding features of the first and secondanchors 150 a, 150 b, if desirable for clarity. The inserter 102 caninclude a distal portion 108 defining an inclined sharp edge 110. Theinserter 102 can define an open longitudinal channel 112. An anchordeploying member 130 can be slidably received in the channel 112 fordeploying the anchors 150 off the inserter 102. The shaft 106 can besolid or hollow, and can operate as a stop member for the anchors 150 a,150 b, which are not loaded in or within the longitudinal channel 112 asin prior art devices, but are instead carried externally and completelyoutside the distal portion 108 of the inserter 102, with no portion ofthe anchors 150 received within the longitudinal channel 112, asdescribed below.

Referring to FIGS. 1, 1A and 2, each flexible anchor 150 can be anelongated member having first and second ends 152, 154. The first andsecond ends 152, 154 are blunt and substantially perpendicular to thelongitudinal axis of the anchor 150. The flexible anchor 150 can be madeof resorbable or non-resorbable materials, including braided suture,sponges and sponge-like materials in solid form, perforated materials,woven/braided from biocompatible materials or fibers, such as, forexample, polymer, polyester, polyethylene, cotton, silk, or othernatural or synthetic materials, include sponges and sponge-likematerials. The flexible anchor 150 can also be an elongated tubular orsolid member or a two-dimensional member with or without internal bores.The flexible anchor 150 can have any properties that allow the flexibleanchor 150 to change shape. The flexible anchor 150 can be, for example,compliant, flexible, foldable, squashable, squeezable, deformable, limp,flaccid, elastic, low-modulus, soft, spongy, perforated or any otherflexible member which can change shape. In some aspects, the flexibleanchor 150 can be coated with biological or biocompatible coatings, andit can also be soaked in platelets and other biologics, which can beeasily absorbed by the flexible anchor 150 in particular when, forexample, the flexible anchor 150 is made from spongy, absorbentmaterial.

It should be understood by the above description that the flexibleanchor 150 cannot pierce or otherwise penetrate tissue either with thefirst and second ends 152, 154, which are blunt or with any otherportion thereof. The flexible anchor 150 can be loaded solely on theexterior of the distal portion 108 of the inserter 102 in a foldedconfiguration, such that the first and second ends 152, 154 are facingeach other. Accordingly, no portion of the flexible anchor 150 isreceived even partially in or within the inserter 102 or the channel112, in contrast to prior art devices in which one or more anchors aresubstantially received within hollow tubular inserters or hollowneedles. More specifically, an intermediate portion 156 of the flexibleanchor 150 can be pierced through by the sharp edge 110 of the inserter102, such that the first and second ends 152, 154 extend opposing oneanother along the proximal portion 108 of the inserter 102, as shown inFIG. 1. The flexible anchor 150 can be in the form of an elongateflexible tube defining a bore 158 along its length, as shown in FIG. 1A.The flexible anchor 150 can be formed of suture braided without a core.

Referring to FIGS. 6-8 the device 100 can include an adjustment actuator500 for the depth limiting device 250. The actuator 500 can be, forexample, a rack-and-gear mechanism for moving the inserter 102 relativeto the depth limiting device 250 between the position shown in FIG. 7,in which the inserter 102 extends a distance “D” beyond a distal end 252of the depth limiting device 250, and the position of FIG. 8, in whichthe inserter 102 extends a distance “D” beyond the distal end 252 of thedepth limiting device 250. The depth limiting device 250 can be in theform of a transparent plastic tube.

The inserter 102 can be used with a cannula 200, shown in FIG. 16. Thecannula 200 can include a handle 202 and a tubular or hollow shaft 204.The shaft 204 of the cannula 200 can have a longitudinal bore 220 havingan inner diameter sized to receive the inserter 102. The shaft 204 ofthe cannula 200 can have a distal end 206 which can be perpendicularrelative to the shaft 204, as shown in FIG. 16, but can also be slantedrelative to the shaft 204. The distal end 206 has a rounded, blunt orsmooth edge not intended to or capable of piercing or otherwisepenetrating tissue. The cannula shaft 204 can include a cut-away slot208 defining a viewing window 210, as shown in FIG. 17.

Referring to FIG. 1A, the flexible anchor 150 can be assembled bent in aU-shape form on the inserter 102 with a continuous strand loop 300attached thereon. The strand loop 300 can be formed by a single segmentof flexible strand 301 passing through the bore 158 of the anchor 150,such that the strand loop 300 includes a first external segment orportion 302 outside the bore 158 and between the ends 152, 154, and asecond external segment portion 304 located outside the bore 158 andexiting the bore 158 from exit openings 160, 162 on opposite sides ofthe bent U-shape of the flexible anchor 150. The flexible strand 301 canbe made of braided filaments or fibers of biocompatible material,including natural and synthetic fibers, such as cotton, silk, polymer,polyester, polyethylene, thin wire, suture, and other materials.

The strand loop 300 can be formed by tying the ends of the segment witha knot 306 which can be positioned on either the first external portion302 or the second external portion 304. It will be appreciated that theloop 300 can define first and second secondary loops or sub-loops 310,312. The first sub-loop 310 can include the first external portion 302,and the second sub-loop can include the second external portion 304. Thefirst and second sub-loops 310, 312 can intersect each other, and eachsub-loop 310, 312 can pass through the bent portion of the bore 158corresponding to the intermediate portion 156 of the flexible anchor150.

Referring to FIGS. 1-6, the deploying member 130 can include anelastically deformable projection 132, which can be used to push theanchor 150 off the inserter 102. The deploying member 130 can be movedaxially along the channel 112 of the inserter 102 by moving a thumbslider 120 of the handle 104 forward or backward relative to the handle104 of the inserter 102, as shown in FIG. 6. In the assembled positionbefore deployment of either anchor 150 a, 150 b, the projection 132 ofthe deploying member 130 can sit behind the first anchor 150 a, as shownin FIG. 1. After the first anchor 150 a is deployed, the deployingmember 130 can be retracted, such that the projection 132 is compressedinward and deformably pulled through the body of second anchor 150 b.When the projection 132 exits the second anchor 150 b, the projection132 springs back to its original shape for pushing the second anchor 150b off the inserter 102, as shown in FIGS. 2 and 3. The loops 300 a, 300b of the first and second anchors 150 a, 150 b can be connected with aflexible strand 350 that has a free end 352 and includes a slip knot 356thereon. The flexible strand 350 can loop around each of the externalsegments 304 a and 304 b, as shown in FIG. 4.

An alternative arrangement for coupling the first and second flexibleanchors 150 a, 150 b with a flexible strand forming an adjustableknotless loop is discussed below in reference to FIGS. 20-24.

Referring to FIGS. 3-5, 9, and 10, the soft tissue repair device 100 canbe used to repair a soft tissue defect 90, such as, for example, a tear,or other weakness in fibrous soft tissue 80, such as in meniscal tissue,cartilage, muscle or other fibrous tissue under the skin. After an outerincision is made through the skin to access the soft tissue 80, thecannula 200 can be positioned through the outer incision without cuttingor piercing any tissue and placed adjacent the fibrous soft tissue 80,as shown in FIG. 10. The cannula 200 can, therefore, operate as anaccess portal for the inserter 102. The inserter 102 can be assembledwith the first and second anchors 150 a, 150 b externally carriedthereon, as shown in FIG. 1.

Referring to FIGS. 9, 10 and 10A, the inserter 102 can be passed throughthe cannula 200 and into the soft tissue 80 from a first side of thedefect 90 until the distal portion 108 of the inserter 102 can exit asecond side 82 of the fibrous soft tissue 80, such as an outer surfaceor back side of a meniscus of a knee joint or other outer surface of afibrous tissue, for example. The deploying member 130 can be movedforward relative to the inserter 102, thereby delivering the firstanchor 150 a on the second side 82 of the soft tissue 80 at a firstlocation, as shown in FIG. 9.

It will be appreciated that the manner and structure of the preassembledinserter 102 and anchor 150 allows the anchor 150 to pass through anarrow opening or slit formed in the tissue 80 by the edge 110 of theinserter 102 in a first low-profile folded configuration defining aplane “A”, as shown in FIG. 2, and deposited in that configurationoutside the tissue 80 with its first and second ends 152, 154 beingdelivered substantially simultaneously. Further, it will be understoodthat tightening the first strand loop 300 by pulling on the secondexternal portion 304 can cause the anchor 150 to deform to a secondconfiguration having a substantially flat round-like or knurled shape.Further pulling on the second external portion 304 can rotate the anchor150 from a first orientation defined by plane A and substantiallyperpendicular to the outer surface 82 to a second orientation such thatthe deformed anchor 150 can define a plane “B” substantially parallel toand lying on the outer surface 82 of the soft tissue 80 in asubstantially flat shape, as shown in FIG. 10.

After the first anchor 150 a is deployed, the deploying member 130 canbe pulled behind the second anchor 150 b. The second anchor 150 b can bepushed off the distal portion 108 of the inserter 102, as shown in FIGS.4 and 5, and be delivered to the second side 82 of the soft tissue 80 ata second location, as shown in FIG. 10. The inserter 102 can then beremoved. The free end 352 of the strand 350 can be tensioned, therebydeforming the second anchor 150 b to a substantially flat round-like orknurled configuration that lays flat on the second side 82 of the softtissue 80, and compressing the defect 90. Any excess portion of thestrand 350 can be cut off.

Referring to FIGS. 11-19, a similar procedure can be used to repair adefect 90 in soft tissue 80 using non-deformable or substantially rigidanchors 600, which can be referenced as first and second anchors 600 a,600 b, if distinction is desirable for clarity. The anchors 600 can bemade of any biocompatible material, such as, for example, titanium orother non-resorbable material, a resorbable or bioabsorbable polymericor other material, including Lactosorb®, commercially available fromBiomet, Inc., Warsaw, Ind. Referring to FIG. 12, each anchor 600 can bea tubular member defining a longitudinal bore 602 that extends betweenfirst and second ends 604, 606 of the anchor 600. The longitudinal bore602 can be substantially D-shaped. The ends 604, 606 of the anchor 600can have rounded edges substantially perpendicular to the anchor 600 a,such that the ends 604, 606 are not capable and not intended forpiercing or penetrating tissue. The anchor 600 can further define atransverse bore 610 oriented at an angle to the longitudinal bore 602,such as, for example, 90-degrees or other suitable angle relative to thelongitudinal bore 602.

The first and second anchors 600 a, 600 b can be coupled with a flexiblestrand 680 that passes through the transverse bore 610 a of the firstanchor 600 a. Both ends 682, 684 of strand 680 can be passed through thetransverse bore 610 b of the second anchor 600 b and tied to a slip knot686, leaving one free end 682 for tightening the strand 680, as shown inFIGS. 11-13A.

Alternatively, flexible strand loops 620 a and 620 b can be formedthrough the respective transverse bores 610 a, 610 b of the first andsecond anchors 600 a, 600 b, as shown in FIG. 14. A flexible strand 680can then be used to connect the two loops 620 a, 620 b, as shown inFIGS. 14A and 15.

Referring to FIGS. 16-19A, the anchor 600 can be inserted throughfibrous tissue using the inserter 102 with the cannula 200, and can beused for fibrous soft tissue repair as described above. In one exemplaryprocedure, the inserter 102 can be passed through the cannula 200 intothe soft tissue 80 from a first side of the defect 90 until the distalportion 108 of the inserter 102 can exit a second side 82 of the softtissue 80, such as an outer surface or back side of a meniscus of a kneejoint or other outer surface of a fibrous tissue, for example. Thedeploying member 130 can be moved forward thereby delivering the firstanchor 600 a on the second side 82 of the soft tissue 80 at a firstlocation, as shown in FIG. 18.

The deploying member 130 can then be pulled behind the second anchor 600b, as the projection 132 is compressed inward and passes through thebore 602 b of the second anchor 600 b. After the projection 132 exitsthe second anchor 600 b, the projection springs back to is originalshape behind the second anchor 600 b. The second anchor 600 b can bepushed off the distal portion 108 of the inserter and be delivered tothe second side 82 of the soft tissue 80 at a second location, as shownin FIG. 19. The inserter 102 can then be removed. The free end 682 ofthe strand 680 can be tensioned, thereby rotating the anchors 600 a, 600b, such that each anchor 600 a, 600 b is positioned with itslongitudinal axis parallel to the surface of the second side 82 of thesoft tissue 80, as shown in FIG. 19A. Tensioning the strand 680 furthercan compress the defect 90. Any excess portion of the strand 380 can becut off.

Alternative non-deformable anchors and loop arrangements are discussedbelow in reference with FIGS. 25A-27.

Referring to FIGS. 20-24, another aspect of coupling the flexibleanchors 150 a, 150 b with a flexible strand 900 is illustrated. Theflexible strand 900 can have first and second ends 902, 904 and can bemade of materials similar to those discussed above in reference to theflexible strand 301. The flexible strand 900 can be braided in a tubularor hollow form such that it forms an internal passage 901 between thefirst and second ends 902, 904. A small knot or other retaining device906 can be optionally formed adjacent the first end 902. The flexiblestrand 900 can be passed through a first opening 160 of each of theflexible anchors 150 a, 150 b, guided along the corresponding bore 158and exit through a second opening 162 of each flexible anchor 150 a, 150b, as shown in FIG. 21. The openings 160, 162 can be positionedintermediately between the first and second ends 152, 154 of eachflexible anchor 150 a, 150 b at a distance of, for example, one-quarterlength from the ends 152, 154 of each flexible anchor 150 a, 150 b.Furthermore, it will be appreciated that the openings 160, 162 can beapertures or voids in the woven fabric of the flexible anchors 150 a,150 b, such that the openings 160, 162 do disrupt or break the weave offlexible anchors 150 a, 150 b, when the flexible anchor 150 a, 150 b aremade of braided or woven material.

After the flexible anchors 150 a, 150 b are mounted on the flexiblestrand 900, the second end 904 of the flexible strand 900 can beinserted into the internal passage 901 of the flexible strand 900 at anaperture 903, guided longitudinally along the passage 901, and led outof the passage 901 of the flexible strand 900 at an aperture 905. Theportion of the strand 900 between apertures 901 and 905 can form anadjustment portion 908 between the optional knot 906 and the opening 160of the second flexible anchor 150 b, such that the flexible strand 900defines a single adjustable knotless loop 910, as shown in FIGS. 22 and22A. The second flexible anchor 150 b can be slidably moved along theflexible strand 900 until the adjustment portion 908 is within the bore158 of the second flexible anchor 150 b and the knot 906 is adjacent theopening 160 of the second flexible anchor 150 b, as shown in FIG. 23. Itwill be appreciated, however, that the adjustment portion 908 can remainin the position shown in FIG. 22. The adjustable knotless loop 910 isself-locking and does not require the surgeon to tie a knot during thesurgical procedure for securing the flexible strand 900. Further, oncethe adjustable knotless loop 910 is self-locked by pulling the secondend 904 of the flexible strand 900 and tensioning the flexible strand900, friction prevents the adjustable knotless loop 910 from beingloosened, thereby providing a secure lock. Additional details regardingforming the knotless adjustable loop 910, and additional adjustableknotless loop configurations are disclosed in co-pending and commonlyassigned U.S. patent application Ser. No. 11/541,506, filed on Sep. 29,2006, the disclosure of which is incorporated herein by reference.

The first and second flexible anchors 150 a, 150 b can be loaded on theinserter 102, as shown in FIG. 1 and discussed above, coupled with theflexible strand 900, which forms the closed adjustable knotless loop910. Pulling the second end 904 of the flexible strand 900 can deformthe first and second flexible anchors 150 a, 150 b for anchoring, andshorten the length of the adjustable knotless loop 910 without using aslipknot. The inserter 102 with the flexible anchors 150 a, 150 bpre-loaded thereon can be used for repairing soft tissue 80, such as ameniscus tear 90, in a similar manner as discussed with reference toFIG. 9, for example. The thumb slider 120 can be moved forward to deploythe first flexible anchor 150 a at an outer surface 82 of the softtissue. The thumb slider 120 can then be moved backward, enabling thedeploying member 130 to be retracted to a position for deploying thesecond flexible anchor 150 b at the outer surface 82 of the soft tissueand adjacent the first flexible anchor 150 a. Pulling the second end 904of the flexible strand 900 can tighten the adjustable knotless loop 910,secure the first and second flexible anchors 150 a, 150 b against theouter surface 82 of the soft tissue 80 and reduce the defect 90.Further, the portions of the sleeve between the first and second ends152, 154 of each of the flexible anchors 150 a, 150 b and thecorresponding first and second openings 160, 162, define anchoring legportions that provide additional resistance for securing the flexibleanchors 150 a, 150 b on the outer surface 82 of the soft tissue 80, asthese leg portions are forced against the outer surface 82 foranchoring.

Referring to FIGS. 25A-27, another non-deformable or substantially rigidanchor 1000 is illustrated. Similarly to the anchors 600 a, 600 billustrated in FIG. 11 the anchor 1000 can be made of any biocompatiblematerial, such as, for example, titanium or other non-resorbable orresorbable material, including polymeric materials and Lactosorb®commercially available from Biomet, Inc., Warsaw, Ind., and can besimilarly used to repair a soft tissue defect 90. The anchor 1000 can betubular defining a longitudinal bore 1002 that extends between first andsecond ends 1004, 1006 of the anchor 1000, and can have an open,channel-like cross-section defining an arc of 180 degrees or more. Theends 1004, 1006 of the anchor 1000 can have blunt rounded edgessubstantially perpendicular to the anchor 1000, such that the ends 1004,1006 are not capable and not intended for piercing or penetratingtissue. The anchor 1000 can further define first and second throughbores 1010 oriented substantially perpendicularly to the anchor 1000 andcommunicating with the longitudinal bore 1002. A flexible strand 900 canbe passed through the through bores 1010 coupling the first and secondanchors 1000 a, 1000 b with an adjustable knotless loop 910, as shown inFIG. 26. The strand 900 can be tightened by pulling on the second end904 of the flexible strand 900 without using a slipknot, as discussedabove.

The first and second anchors 1000 a, 1000 b, coupled with the flexiblestrand 900, can be mounted on a single inserter 102, as described abovein connection with FIG. 11. Another exemplary inserter 1050 for use withthe first and second anchors 1000 a, 1000 b is shown in FIG. 27. Theinserter 1050 can have a cylindrical body 1052, a pointed distal tip1054, and a stop 1056. The first anchor 1000 a can be mounted externallyonto the body 1052 of the inserter 1050 between the tip 1054 and thestop 1056, such that a portion of the inserter 1052 is received in thelongitudinal bore 1002 of the first anchor 1000 a. The second anchor1000 b can be similarly mounted externally onto the body 1052 of theinserter 1050 behind the first anchor 1000 a and facing in a directionopposite to the first anchor 1000 a and opposite to the stop 1056.

In use, the inserter 1050 can be pushed through the soft tissue 80 andthrough the defect 90 to the outer surface 82 of the soft tissue 80carrying the first anchor 1000 a therethrough. The stop 1056 preventsthe anchor 1000 a from sliding backward when the inserter 1050 isretracted out of the soft tissue 80, leaving the first anchor 1000 a onthe outer surface 82. The second anchor 1000 b can be then slid alongthe body 1052 of the inserter 1050 opposite the stop 1056, rotated about180 degrees to be positioned directly behind the stop 1056 and deployedoff the inserter 1050 similarly to the deployment of the first anchor1000 a. In one aspect, the anchors 1000 a and 1000 b can be mounted in akeyed manner onto the inserter 1050, such that accidental relativerotation can be substantially prevented without preventing intentionalsliding and rotation of the anchors. In a related aspect, more than twoanchors can be loaded on the inserter 1050. Two additional anchors, forexample, can be loaded behind the stop 1056. In this aspect, the fouranchors can be loaded at 90-degrees circumferentially apart on theinserter 1050, and can be deployed sequentially, with a 90-degreerelative rotation of the inserter 1050 relative to each anchor, afterdeployment of the previous anchor.

It will be appreciated from the above description and drawings that thepresent teachings provide anchors of versatile configurations that canbe passed through tissue easily in a compact or low profileconfiguration and or orientation and then positioned outside tissue in asecond orientation that provides anchoring without tissue penetration,preventing withdrawal from the tissue and reducing tissue injury.Further, the use of an inserter provided with preassembled anchors canhelp reduce the time length of the procedure and simplify manipulationsrequired during the procedure.

It will be further understood that the various embodiments of theinserters, anchors and coupling arrangements can be mixed and matched orcombined in ways other than those explicitly discussed above, withoutdeparting from the scope of the present teachings.

The foregoing discussion discloses and describes merely exemplaryarrangements of the present invention. One skilled in the art willreadily recognize from such discussion, and from the accompanyingdrawings and claims, that various changes, modifications and variationscan be made therein without departing from the spirit and scope of theinvention as defined in the following claims.

What is claimed is:
 1. A meniscal tissue repair device, comprising: anouter tube, the outer tube comprising an open distal end and alongitudinal bore that extends through the outer tube to the open distalend; an inserter received in the longitudinal bore of the outer tube,the inserter including a distal portion with an inclined sharp edge forpiercing through meniscal tissue, the inserter further including alongitudinal channel that extends to the distal portion of the inserter;a first flexible tubular anchor deployable from the inserter at a firstlocation along an outer surface of a meniscus; a second flexible tubularanchor deployable from the inserter at a second location along the outersurface of the meniscus, wherein, prior to deployment of the firstflexible tubular anchor from the inserter along the outer surface of themeniscus, the second flexible tubular anchor is located proximal of thefirst flexible tubular anchor along the inserter; a suture coupling thefirst flexible tubular anchor to the second flexible tubular anchor; anda deploying member, the deploying member including a proximal shaftportion and a projection that projects from a side of the deployingmember at a distal end of the deploying member, the deploying memberhaving a first width at the proximal shaft portion and a second width atthe projection that is greater than the first width, the deployingmember slidably received in the longitudinal channel of the inserter,wherein, prior to deployment of the first flexible tubular anchor fromthe inserter along the outer surface of the meniscus, the deployingmember extends to the first flexible tubular anchor through the secondflexible tubular anchor along the longitudinal channel of the inserter,wherein the projection is configured to: engage the first flexibletubular anchor prior to deployment of the first flexible tubular anchorfrom the inserter along the outer surface of the meniscus; be advanceddistally along the inserter while so engaging the first flexible tubularanchor so as to force the first flexible tubular anchor from theinserter at the first location along the outer surface of the meniscus;be retracted proximally along the inserter and into engagement with thesecond flexible tubular anchor; and be advanced distally along theinserter while so engaging the second flexible tubular anchor so as toforce the second flexible tubular anchor from the inserter at the secondlocation along the outer surface of the meniscus.
 2. The meniscal tissuerepair device of claim 1 further comprising a hollow shaft received inthe longitudinal bore of the outer tube, the hollow shaft received overthe deploying member with a distal end of the hollow shaft contactingthe second flexible tubular anchor to provide a stop for the secondflexible tubular anchor.
 3. The meniscal tissue repair device of claim1, wherein the projection is configured to engage an intermediateportion of the first flexible tubular anchor prior to deployment of thefirst flexible tubular anchor from the inserter along the outer surfaceof the meniscus, the intermediate portion located between a first endand a second end of the first flexible tubular anchor.
 4. The meniscaltissue repair device of claim 1, wherein the suture comprises anadjustable loop.
 5. The meniscal tissue repair device of claim 4,wherein the adjustable loop is a knotless adjustable loop.
 6. A meniscaltissue repair device, comprising: an outer tube, the outer tubecomprising an open distal end and a longitudinal bore that extendsthrough the outer tube to the open distal end; an inserter received inthe longitudinal bore of the outer tube, the inserter including a distalportion with an inclined sharp edge for piercing through meniscaltissue, the inserter further including a longitudinal channel thatextends to the distal portion of the inserter; a first flexible tubularanchor deployable from the inserter at a first location along an outersurface of a meniscus; a second flexible tubular anchor deployable fromthe inserter at a second location along the outer surface of themeniscus, wherein, prior to deployment of the first flexible tubularanchor from the inserter along the outer surface of the meniscus, thesecond flexible tubular anchor is located proximal of the first flexibletubular anchor along the inserter; a suture coupling the first flexibletubular anchor to the second flexible tubular anchor; and a deployingmember received in the longitudinal channel of the inserter andincluding a projection that projects from a side of the deployingmember, the deploying member longitudinally slidable in the longitudinalchannel of the inserter from a first deployment position to additionaldeployment positions for deploying the first flexible tubular anchor andthe second flexible tubular anchor from the inserter along the outersurface of the meniscus, wherein, in the first deployment position, thedeploying member, while received in the longitudinal channel of theinserter, extends through the second flexible tubular anchor such thatthe projection is located distally of the second flexible tubular anchorand engages an intermediate portion of the first flexible tubularanchor, the intermediate portion located between a first end and asecond end of the first flexible tubular anchor, wherein the deployingmember is movable distally in the longitudinal channel of the inserterfrom the first deployment position to a second deployment position tothereby force the first flexible tubular anchor to move distallyrelative to the inserter, wherein, in the second deployment position,the deploying member remains extending through the second flexibletubular anchor and the projection engages the first flexible tubularanchor distally of the inclined sharp edge of the distal portion of theinserter for deploying the first flexible tubular anchor from theinserter, wherein the deploying member is movable proximally in thelongitudinal channel of the inserter from the second deployment positionto a third deployment position, wherein, in the third deploymentposition, the projection: (i) no longer engages the first flexibletubular anchor; and (ii) has been pulled back through at least part ofthe second flexible tubular anchor, and wherein the deploying member ismovable distally in the longitudinal channel of the inserter from thethird deployment position to a fourth deployment position to therebyforce the second flexible tubular anchor to move distally relative tothe inserter, wherein, in the fourth deployment position, the projectionengages the second flexible tubular anchor distally of the inclinedsharp edge of the distal portion of the inserter for deploying thesecond flexible tubular anchor from the inserter.
 7. The meniscal tissuerepair device of claim 6 further comprising a hollow shaft received inthe longitudinal bore of the outer tube, the hollow shaft received overthe deploying member with a distal end of the hollow shaft contactingthe second flexible tubular anchor to provide a stop for the secondflexible tubular anchor.
 8. The meniscal tissue repair device of claim6, wherein the deploying member includes a proximal shaft portion, andwherein the projection is located at a distal end of the deployingmember, the deploying member having a first width at the proximal shaftportion and a second width at the projection that is greater than thefirst width.
 9. The meniscal tissue repair device of claim 6, whereinthe suture comprises an adjustable loop.
 10. The meniscal tissue repairdevice of claim 9, wherein the adjustable loop is a knotless adjustableloop.
 11. The meniscal tissue repair device of claim 6, wherein theprojection is an elastically deformable projection.
 12. A meniscaltissue repair device, comprising: an outer tube, the outer tubecomprising an open distal end and a longitudinal bore that extendsthrough the outer tube to the open distal end; an inserter received inthe longitudinal bore of the outer tube, the inserter including a distalportion with an inclined sharp edge for piercing through meniscaltissue, the inserter further including a longitudinal channel thatextends to the distal portion of the inserter; a first flexible tubularanchor deployable from the inserter at a first location along an outersurface of a meniscus; a second anchor coupled to the first anchor witha suture and deployable from the inserter at a second location along theouter surface of the meniscus, wherein, prior to deployment of the firstflexible tubular anchor from the inserter along the outer surface of themeniscus, the second flexible tubular anchor is located proximal of thefirst flexible tubular anchor along the inserter; and a deploying membermovable back and forth in the longitudinal channel of the inserter fordeploying the first flexible tubular anchor and the second flexibletubular anchor from the inserter, the deploying member including aprojection that projects from a side of the deploying member, theprojection positioned distal of the second flexible tubular anchor alongthe inserter while the deploying member is extending through the secondflexible tubular anchor and while the projection is engaging anintermediate portion of the first flexible tubular anchor so that, viaengagement of the intermediate portion with the projection, the firstflexible tubular anchor can be forced from the inserter when thedeploying member is moved distally in the longitudinal channel, theintermediate portion located between a first end and a second end of thefirst flexible tubular anchor.
 13. The meniscal tissue repair device ofclaim 12, wherein the deploying member is movable back through thelongitudinal channel of the inserter in a proximal direction followingdeployment of the first flexible tubular anchor from the inserter suchthat the projection passes through at least part of the second flexibletubular anchor and into engagement with the second flexible tubularanchor so that, via engagement of the second flexible tubular anchorwith the projection, the second flexible tubular anchor can be forcedfrom the inserter when the deploying member is again moved distally inthe longitudinal channel.
 14. The meniscal tissue repair device of claim12, wherein the deploying member includes a proximal shaft portion, andwherein the projection is located at a distal end of the deployingmember, the deploying member having a first width at the proximal shaftportion and a second width at the projection that is greater than thefirst width.
 15. The meniscal tissue repair device of claim 12, whereinthe longitudinal channel of the inserter includes a channel opening on aside of the inserter, and wherein a portion of the suture coupling thefirst flexible tubular anchor to the second flexible tubular anchorextends through the channel opening so as to reside outside of theinserter.
 16. The meniscal tissue repair device of claim 12, wherein thesuture comprises an adjustable loop.
 17. The meniscal tissue repairdevice of claim 16, wherein the adjustable loop is a knotless adjustableloop.
 18. The meniscal tissue repair device of claim 12, wherein thefirst flexible tubular anchor and the second flexible tubular anchoreach comprise a braided suture material.
 19. A meniscal tissue repairdevice, comprising: an outer tube, the outer tube comprising an opendistal end and a longitudinal bore that extends through the outer tubeto the open distal end; an inserter received in the longitudinal bore ofthe outer tube, the inserter including a distal portion with an inclinedsharp edge for piercing through meniscal tissue, the inserter furtherincluding a longitudinal channel that extends to the distal portion ofthe inserter; a first flexible tubular anchor deployable from theinserter at a first location along an outer surface of a meniscus; asecond flexible tubular anchor deployable from the inserter at a secondlocation along the outer surface of the meniscus, wherein, prior todeployment of the first flexible tubular anchor from the inserter alongthe outer surface of the meniscus, the second flexible tubular anchor islocated proximal of the first flexible tubular anchor along theinserter; a suture coupling the first flexible tubular anchor to thesecond flexible tubular anchor; and a deploying member received in thelongitudinal channel of the inserter, the deploying member including aproximal shaft portion and a projection that projects from a side of thedeploying member at a distal end of the deploying member, the deployingmember having a first width at the proximal shaft portion and a secondwidth at the projection that is greater than the first width, thedeploying member longitudinally slidable in the longitudinal channel ofthe inserter from a first deployment position to additional deploymentpositions for deploying the first flexible tubular anchor and the secondflexible tubular anchor from the inserter along the outer surface of themeniscus, wherein, in the first deployment position, the deployingmember, while received in the longitudinal channel of the inserter,extends through the second flexible tubular anchor and into engagementwith the first flexible tubular anchor, wherein the deploying member ismovable distally in the longitudinal channel of the inserter from thefirst deployment position to a second deployment position to therebyforce the first flexible tubular anchor from the inserter at the firstlocation along the outer surface of the meniscus, wherein, in the seconddeployment position, the deploying member remains extending through thesecond flexible tubular anchor, wherein the deploying member is movableproximally in the longitudinal channel of the inserter from the seconddeployment position to a third deployment position to thereby retractthe projection relative to the inserter and move the projectionproximally through at least part of the second flexible tubular anchor,and wherein the deploying member is movable distally in the longitudinalchannel of the inserter from the third deployment position to a fourthdeployment position to thereby force the second flexible tubular anchorfrom the inserter at the second location along the outer surface of themeniscus.
 20. The meniscal tissue repair device of claim 19 furthercomprising a stop member contacting the second flexible tubular anchorfor preventing the second flexible tubular anchor from sliding backwardsrelative to the inserter.
 21. The meniscal tissue repair device of claim19, wherein the longitudinal channel of the inserter includes a channelopening on a side of the inserter, and wherein, in the first deploymentposition, a portion of the suture coupling the first flexible tubularanchor to the second flexible tubular anchor extends through the channelopening so as to reside outside of the inserter.
 22. The meniscal tissuerepair device of claim 19, wherein the suture comprises an adjustableknotless loop.
 23. The meniscal tissue repair device of claim 19,wherein, in the first deployment position, the projection engages anintermediate portion of the first flexible tubular anchor, theintermediate portion located between a first end and a second end of thefirst flexible tubular anchor.